Annual Physical Exam Fasting Instructions Form
Please complete this form to confirm your understanding and compliance with fasting instructions for your annual physical exam.
Full Name
*
First Name
Last Name
Date of Birth (Month/Day/Year)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Scheduled Physical Exam
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Scheduled Physical Exam
*
Hour Minutes
AM
PM
AM/PM Option
Have you fasted (no food or drink except water) for at least 8 hours prior to your exam?
*
Yes, I have fasted as instructed.
No, I have not fasted.
Partially (please explain below)
Have you taken any medications or consumed anything other than water during your fasting period?
*
No, only water
Yes, prescription medication (please specify below)
Yes, food or drink (please specify below)
If you answered 'Partially' or 'Yes' above, please provide details (medication, food, or drink consumed):
Submit
Should be Empty: